Download Pediatric Warfarin Order Form INR 2-3

The Warfarin Order Sheet has been approved by the P & T committee to be implemented by pharmacists.
These orders are not used to treat patients with serious hemorrhagic complications.
WARFARIN TARGET INR 2-3 ORDER SHEET
PATIENT NAME:_________________________________ DIAGNOSIS:___________________________________________
WEIGHT:___________kg HEIGHT:___________cm ALLERGIES:______________________________________________
INR Range
Target INR
Indications:  Prophylaxis of venous thrombosis (VTE)
2-3
2.5
2-3
2.5
 Treatment of venous thrombosis (VTE)
2-3
2.5
 Pulmonary embolism (PE)
 Atrial flutter/fibrillation
2-3
2.5
 Recurrent systemic embolism
2-3
2.5
 Acute/subacute thrombo-embolic stroke
2-3
2.5
 Cerebral sinovenous thrombosis
2-3
2.5
 Other________________________________
________
________
Hematology
Consult:




Laboratory
Tests:
 Patient starting therapy:
 Prior to first dose obtain:
 PT/INR
 CBC
 Beta HCG for females greater than or equal to 12 years of age or post-menarche.
 INR every morning.
 CBC every 3 days.
 Patient is on maintenance therapy:
 INR if the patient is on warfarin when admitted and an INR has not been drawn in the last week.
 INR weekly if patient is stabilized at goal INR: most recent INR _________ Date_________
Dosing:
 RPh will refer to the dosing nomogram below to calculate and order warfarin dose daily
Patient is receiving other medications that can affect warfarin.
Patient has liver disease, protein C deficiency or Fontan.
Patient is an infant
Other_____________________________________________
Contact LIP  Concern for bleeding: guaiac positive, drop in platelet count or HgB, headache or change in neuro exam
 Continue patient’s therapeutic home dose of __________________________ mg PO daily at 2000.
Loading dose
 *Initial loading dose: __________ mg (0.2 mg/kg) warfarin (max dose 10 mg) PO daily at 2000.
 Liver disease, protein C deficiency or Fontan: Initial loading dose: _________ mg (0.1 mg/kg)
warfarin (max dose 5 mg) PO daily at 2000.
 Other initial loading dose: ___________ mg warfarin (max dose 10 mg) PO daily at 2000.
 Orders to be written by patient’s LIP according to the warfarin policy and guideline.
Ongoing dosing and labs to be ordered by pharmacy according to nomogram.
*INITIAL DOSING (days 2-4) for INR goal 2-3
INR
Dosing
1.1 – 1.3
Repeat initial dose(consider bridge therapy)
1.4 – 1.9
Give 50% of initial dose
2–3
Give 50% of initial dose
3.1 – 3.5
Give 25% of initial dose
Hold dose until INR less than 3.5, then restart
Greater than 3.5
at 20% less than previous dose. Notify LIP if
greater than 3.5 for two days
MAINTENANCE DOSING (5 days or more ) for INR goal 2-3
INR
Dosing
1.1 – 1.4
Increase total weekly dose by 20%
1.5 – 1.9
Increase total weekly dose by 10%
2–3
Continue current dose
3.1 – 3.5
Decrease total weekly dose by 10%
Hold dose until INR less than 3.5, then restart
Greater than
at 20% less than previous dose. Notify LIP if
3.5
greater than 3.5 for two days
Signature:_____________________________________________ (MD/LIP) Date:_____________ Time:_____________
Print Name: ________________________________________
Signature: _______________________________________ (RN)
Date:_____________ Time:_____________
Signature: _______________________________________ (HUC) Date:_____________ Time:_____________
WARFARIN TARGET INR 2-3 ORDERS Page 1 of 2
PHA313 (05/2012) Rev; 09/2015
PEDIATRIC WARFARIN GUIDELINE TARGET INR 2-3 (August 2015)
TREATMENT OR PROPHYLAXIS FOR
 Venous thromboembolism (VTE)
 Pulmonary embolism
 Atrial flutter/fibrillation
 Other
CONTRAINDICATIONS
 Active bleeding or significant bleeding within the last 24 hours
 INR greater than 2
 Received thrombolytic therapy within the last 12 hours
 Known or suspected hemorrhagic stroke
 Monotherapy with recently diagnosed HIT
 Risk for intracranial/intraocular hemorrhage





Epidural anesthesia
Active TB (use with caution)
Pregnancy (teratogenic)
Hypersensitivity to warfarin
Hematuria
 Hemorrhagic disorders
Consider Hematology consult
NOTIFY LIP if the patient develops any of the following:
 Bleeding or positive stool guaiac
 INR greater than 3.5 for two days
 Platelet count less than 100,000/cumm or 2-gram drop in Hgb
 Unusual headache or change in neurological exam
 Interacting medications
DAILY CARE
 Consider discontinuing aspirin containing products and anti-inflammatory medications (NSAIDS).
 No intramuscular injections/Avoid unnecessary venous or arterial punctures.
 Guaiac stools that appear black, tarry, or contain frank blood.
 No vitamin K supplements or foods rich in vitamin K (dietary to be alerted of patients on warfarin).
BRIDGING GUIDELINES
Medication
How long to hold
prior to procedure
Enoxaparin
12 hours
Warfarin
2-5 days
Goal INR less than 1.4
Aspirin
7 days
Heparin
4-6 hours
Goal Anti Xa less than 0.35
Clopidogrel
5-7 days
Rivaroxaban
24 hours
LABS
 Prior to first dose draw (if not drawn within last 24 hours) PTT, PT/INR, fibrinogen and CBC. Draw a Beta
HCG for females older than 12 yr or post-menarche.
 Draw an INR if the patient is on warfarin when admitted and an INR has not been drawn in the last week.
 Draw an INR every morning until stable for 2 days and then weekly.
 Draw a CBC every three days for two weeks then weekly.
 Increase frequency of monitoring with evidence of bleeding
Dosage and Administration of Warfarin
 If initial labs are appropriate, order a 0.2 mg/kg dose of warfarin – rounded to nearest 0.5mg (max dose 10
mg) to be given at 2000.
 *Average dose to obtain INR 2-3 is 0.33mg/kg for infants and 0.09mg/kg for teens
 Consider hematology consult for possible dose adjustments if:
o Patient is receiving other medications that interact with warfarin.
o Patient has underlying liver dysfunction or Fontan procedures – consider 0.1mg/kg (max dose 5 mg).
o If unable to achieve therapeutic levels consider switching to low molecular weight heparin.
 Once INR is therapeutic, calculate the average daily dose by summing the total loading dose (up to 7
days) and dividing by the number of days needed to load
CONVERSION TO ORAL ANTICOAGULANT THERAPY: Continue enoxaparin/heparin for at least five days in
combination with warfarin therapy. Ensure INR is therapeutic for at least two days prior to stopping Enoxaparin/heparin.
These are intended to be a guide to common clinical circumstances, and may not apply to certain patients and situations.
The treating clinician must use judgment in application of guidelines to the care of individual patients.
WARFARIN TARGET INR 2-3 ORDERS Page 2 of 2
PHA313 (05/2012) Rev; 09/2015